Birmingham and Solihull Mental Health NHS Foundation Trust. Integrated Quality Committee Terms of Reference

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1 1 Authority Birmingham and Solihull Mental Health NHS Foundation Trust Integrated Quality Committee Terms of Reference 1.1 The Integrated Quality Committee is constituted as a Standing Committee of the Trust Board. Its constitution and terms of reference shall be as set out below, subject to amendment at future Trust Board meetings. 1.2 The Committee is authorised by the Trust Board to request the attendance of individuals and authorities from outside the Trust with relevant experience and expertise if it considers this necessary. 1.3 The committee is authorised by Trust Board to carry out any function within its terms of reference. 2. Purpose 2.1 The primary purpose of the committee is to ensure, on behalf of the Board that the Trust is aiming to achieve the highest standards of quality around safety, patient experience and clinical effectiveness, as outlined in the Well Led Framework, the Quality Strategy and Quality Accounts. The committee will monitor progress against implementation of these key documents and will provide assurance to the Trust Board on the effectiveness of the quality and safety of services, to ensure that there is no negative impact on quality due to financial decision making; and to ensure regulatory compliance in respect of quality. 2.2 The committee is responsible for seeking assurance on people productivity elements of the trusts work this includes human resources and staff support and experience and the People s Plan 2.3 Seek any and all explanations and information it requires from any employee or contractor of the organisation to achieve the committee s purpose. 2.4 To approve policies identified for sign off at IQC, in line with the Policy Development and Management policy. 3. Duties 3.1 To provide assurance to Trust Board that the quality, safety and effectiveness of clinical services are appropriate. 3.2 To ensure compliance with the regulatory standards of clinical staff. 3.3 To review the top risks from risk registers on a quarterly basis in order to identify those, related to quality and safety, which need to be included on the

2 Board Assurance Framework and to provide assurance to Trust Board that effective structures are in place to measure and continuously improve the effectiveness of care and that effective plans are in place to mitigate risk and ensure plans are implemented effectively. 3.4 To provide assurance to the Trust Board that the Trust is listening to patients about their experience and to take account of issues that might indicate that individuals /groups of patients may be having and poorer experience, including exploring complaints and adverse trends. 3.5 To provide focus on quality and improvement for patients and users of the Trust s services and to provide assurance in relation to quality defined as safety, effectiveness and patient experience 3.6 To ensure that the themes and lessons arising from any investigation and review of serious incident claims and complaints, or homicide reviews are consistently shared across the organisation and the actions arising are effectively implemented and make appropriate recommendations to the Trust Board. 3.7 To review, approve and monitor implementation and impact of the Trust s Quality Strategy and Quality Account. 3.8 To ensure Medical Director and Director of Nursing sign off has been received in respect of impact on quality for all service redesign plans. 3.9 To receive exception reports from FPP, and scrutinise these, in relation to financial outcomes or plans which may have the potential to impact on quality and ensure this is discussed at the committee and views fed back by exception report to FPP 3.10 To provide assurance to Trust Board that the Trust has adequate systems and processes in place to ensure and continuously improve patient safety and management of risk from Ward to Board To consider actual Trust performance against external benchmark information in relation to quality and safety, people and HR, as an aid to the overall effectiveness and efficiency of the Trust 3.12 To receive monthly quality dashboard reports around an agreed set of Key Performance Indicators to measure effectiveness, safety and experience to be determined by the Committee To receive reports from Divisions outlining their structures and processes for managing and monitoring Quality, Risk, Safety and quality governance and to assure itself and the Trust Board that divisions are giving appropriate priority to continuous improvement.

3 3.14 Where performance in respect of quality and patient safety has fallen short of agreed standards, or there has been some other indication of a diminution of standards, the Committee has the delegated authority to request evidence of assurance that the concerns have been investigated, corrective action has been taken and lessons have been learnt To have oversight of mortality information and any associated learning arising from mortality case note review 4. Members 4.1 The membership of the committee will be Chair - Non-Executive Director Deputy Chair - Non-Executive Director Non-Executive Director Executive Director of Nursing Medical Director Executive Director of Operations Company Secretary Associate Director of Governance Other Directors will attend if they have an agenda item but only for that item All members will have one vote. In the event of votes being equal the Chair of the Committee will have the casting vote In the absence of the Chair of the Committee, the Deputy Chair will chair the meeting 4.13 Other Board members will have the right to attend the committee but will be required to advise the Chair of IQC in advance of their intention to do so The Trust Chair and Chief Executive will be non-voting ex-officio members of the Committee and will be entitled to attend any or all committee meetings. They will also receive all Committee reports Where members are unable to attend they are entitled to, and in the case of Executive Directors, expected to nominate a deputy to attend in advance of the meeting. Such a deputy will be expected to be briefed and entitled to utilise the members vote at the meeting Non-members can attend the meeting with the prior agreement of the Committee chair Members are expected to make every effort to attend all meetings of the Committee.

4 4.18 Meeting attendance will be reviewed by the Committee chair annually. 5. Quoracy 5.1 The meeting will be considered quorate with 3 Committee members, one of which must be a Non-Executive Director and one must be an Executive Director. 6. Declaration of interests 6.1 All members and attending ex-officio members must declare any actual or potential conflicts of interest in advance. These must be recorded in the minutes. Members must exclude themselves from any part of the meeting where a potential or actual conflict of interest may occur. 7. Meetings 7.1 Meetings will be held monthly. 7.2 Meeting dates will be agreed annually in advance by the members of the Committee. 7.3 To include as a standing item on every agenda the Committee should review how effectively it has discharged its business at that meeting. 8. Administration 8.1 The meeting will be closed and not open to the public. 8.2 The Company Secretary will ensure there is appropriate secretarial and administrative support to the Committee. 8.3 An action list and minutes will be compiled during the meeting and circulated within 7 calendar days of the end of the meeting. 8.4 Any issues with the action list or minutes will be raised within 7 calendar days of issue. 8.5 The Executive Director of Nursing will agree a draft agenda with the Committee Chair and it will be circulated 7 calendar days after the previous meeting to allow time for input, with the final version circulated with papers. 8.6 The Board Support Officer will be responsible for updating the forward plan with input from the Director of Nursing and Associate Director of Governance, for agreement with the Chair of the Committee 8.6 Any issues with the agenda must be raised with the Committee chair within 4 working days.

5 8.7 All final Committee reports must be submitted 7 calendar days before the meeting. 8.8 The agenda, minutes and all reports will be issued 6 calendar days before the meetings. 9. Reporting and links to other committees 9.1 The Committee will receive regular reports from the groups reporting into it the formal timing of these will be outlined on the IQC forward plan and in addition to this exception reports will be provided as required Clinical Governance Committee Mortality Surveillance Group Clinical Senate (by way of quarterly reports) 9.2 The Committee will report to Trust Board at the next meeting reporting on any significant issues. 9.3 The Committee will provide exception reports to the Audit Committee 9.4 To support overlap between IQC and FPP the Chair and CEO will provide this through their frequent attendance at both meetings. Anything involving service changes will require sign off in terms of impact on quality by the Medical Director and the Director of Nursing. Attendees at both IQC and FPP will be expected to have an eye on the need for an integrated approach so that impact issues are not lost, and papers to both committees will need to indicate where there is a potential impact on quality. Where necessary, exception reports will be provided between the two committees. 9.5 The Chair of IQC and the Chair of MHLC will discuss any potential areas of duplication in their remits and ensure this is rectified in work planning and later amendments to their respective TORs. 9.6 The Committee will review their effectiveness on an annual basis, reporting the outcome of the review to Trust Board 9.7 The Committee Chair will present to the Council of Governors annually a report on the work of the Committee. Approved in March 2016 Trust Board.